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•Entnmental Health Department <br />AN41aAQUIN -��� <br />- —COUNTY--- . <br />li lac � � <br />c� <br />APPLICATION FOR UNDERGROUND STORAGE TANK JUL. � - I <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW1 II AI THI f FPAM o ti MENT <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STA Ft VR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas 916-373-1166 <br />� <br />Facility Name Quik Stop #152 <br />Phone # 510-657-8500 <br />� <br />Address 1721 S. Cherokee Ln #1 Lodi CA 95240 <br />1 <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # <br />o <br />Contractor Name Walton En ineerin Inc. <br />Phone # 916-373-1166 <br />T <br />Contractor Address P.O. Box 1025, West Sacramento, CA 95691 <br />CA Lic # 617238 Class ABHaz <br />R <br />A <br />Insurer See Attached <br />Work Comp # <br />cT <br />ICC Technician's Name Ton Reyes <br />Expiration Date 10-17-18 <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />87 STP <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Mari J � <br />Plan Reviewers Name Date �1, g <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title Compliance Manager Date 7/27/18 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br />acknowledge this responsibility for the billing by signature and date below. <br />NAME Walton Frigineering, ■ •■ •- PHONE#• • ■• <br />ADDRE <br />SIGNATU <br />2 of 6 <br />TE 7/27/18 <br />